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Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University Hospital, Project and Development Department.
2008 (English)In: Quality and Safety in Healthcare, ISSN 1475-3898, E-ISSN 1475-3901, Vol. 17, no 4, 281-285 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment. METHODS: All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel-methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers. RESULTS: In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively. The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006. CONCLUSIONS: The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.

Place, publisher, year, edition, pages
2008. Vol. 17, no 4, 281-285 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-87828DOI: 10.1136/qshc.2007.023341ISI: 000258186500012PubMedID: 18678726OAI: oai:DiVA.org:uu-87828DiVA: diva2:133752
Available from: 2009-01-14 Created: 2009-01-14 Last updated: 2011-02-01Bibliographically approved

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